The cecum and the vermiform appendix

The cecum is the first part of the large intestine. It begins caudally from the ileocecal valve and ends blindly in the right iliac fossa. The vermiform appendix is attached dorsomedially to the end of the cecum.

Macroscopic Anatomy

Cecum

Typically, the cecum is located intraperitoneally in the right lower abdomen and has a length of 5 to 7 cm. However, due to an incomplete rotation of the umbilical loop during embryogenesis it may lie quite variably. Therefore clinically, one differentiates between three important variations:

As in the colon, taeniae, haustra and semilunar folds are found in the cecum but no appendices epiploicae.

The cecum is supplied by the anterior and posterior cecal arteries. The venous blood drains through the correspondent veins into the superior mesenteric vein. The cecum is innervated by the superior mesenteric plexus, whereas the parasympathetic fibers come from the vagus nerve (cranial nerve X).

Anterior cecal artery - ventral view

Vermiform Appendix

The vermiform appendix is attached dorsomedially to the end of the cecum, where all three taeniae converge. It is 2 to 15 cm long and lies often intraperitoneallyretrocecal (65%) or in the lesser pelvis (30%). The appendix is attached to the posterior abdominal wall by the mesoappendix. Here taeniae, haustra, semilunar folds and appendices epiploicae are all absent.

The appendix is supplied by the appendicular artery (all branches of the ileocolic artery from the superior mesenteric artery). The venous blood drains through the correspondent veins into the superior mesenteric vein. Similar to the cecum, the appendix is innervated by the superior mesenteric plexus, whereas the parasympathetic fibers come from the vagus nerve (cranial nerve X).

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Structure of the large intestine, including the mucosa and musculature.

Histologically the appendix looks quite similar to the colon and cecum. A distinctive feature is however the numerous lymph follicles and the parafollicular tissue in the connective tissue layer of the mucosa (lamina propriae mucosae) and the submucosa. The crypts are particularly deep so that the follicles are in close contact to the intestinal lumen. M-cells (microfold cells) are found in the epithelium which access antigens from the intestinal lumen. As the appendix lacks taeniae it has a regular outer longitudinal musculature.

Crypts of Lieberkuhn - histological slide

Function

Cecum

The main tasks of the cecum are the absorption of water and salts and the lubrication of the feces with mucus. Especially components from plant-rich food (e.g. cellulose) are bacterially decomposed here. This explains why herbivores have considerably larger ceca in comparison to carnivores.

Appendix

The appendix is part of the GALT (gut-associated lymphatic tissue) and fulfills immunological functions. Furthermore it is assumed that it serves as a “safe house” for enterobacteria (e.g. in case of diarrhea). On the picture you can see an inflamed vermiform appendix which was removed operatively.

Appendicitis

As the name implies, this condition involves the inflammation of the appendix. The main cause of appendicitis is a blockage of the appendix itself, often due to faecal matter, an infection, foreign body or a tumour. As a result, the appendix can burst or perforate if left untreated. It is a very dangerous condition that is considered a medical emergency due to potential severe complications, like peritonitis, if it is not managed.

Acute appendicitis

The signs and symptoms of appendicitis include:

pain that extends from the navel (dull) towards the lower-right portion of the abdomen (sharp)

loss of appetite

nausea and vomiting

abdominal swelling

fever

The majority of time, treatment of appendicitis involves an appendectomy (removal of the appendix).

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